CONFIDENTIAL INTERNAL USE PUBLIC UPON APPROVAL
DOCUMENT OF THE INTER-AMERICAN DEVELOPMENT BANK
JAMAICA
SUPPORT FOR THE HEALTH SYSTEMS STRENGTHENING FOR THE PREVENTION AND CARE MANAGEMENT OF NON-COMMUNICABLE DISEASES PROGRAMME II
(JA-L1086)
LOAN PROPOSAL
This document was prepared by the project team consisting of: Ricardo Pérez Cuevas (SPH/CJA) and Pablo Ibarrarán (SCL/SPH) CoTeam- Leaders; Ian Mac Arthur (SPH/CBR); Jennifer Nelson, Isabel Delfs Ilieva, and Sheyla Silveira (SCL/SPH); Rene Herrera, and Naveen Jainauth-Umrao (FMP/CJA); Henry Mooney, Jason Craig Christie, and Nicole Brown (CCB/CJA); Louis Francois- Chrétien (LEG/SGO); and Charles Steven Collins (VPS/ESG).
This document contains confidential information relating to one or more of the ten exceptions of the Access to Information Policy and will be initially treated as confidential and made available only to Bank Employees. The document will be discussed and made available to the public upon approval. CONTENTS
PROJECT SUMMARY ...... 1
I. PROJECT DESCRIPTION AND RESULTS MONITORING ...... 2
A. Background, problem addressed, and justification ...... 2 B. Objective, components, and cost...... 17 C. Key results indicators ...... 20
II. FINANCING STRUCTURE AND MAIN RISKS ...... 21
A. Financing instruments ...... 21 B. Environmental and social risks ...... 21 C. Fiduciary risk...... 22 D. Other key issues and risks ...... 22
III. IMPLEMENTATION AND MANAGEMENT PLAN ...... 22
A. Summary of implementation arrangements ...... 22 B. Summary of arrangements for monitoring results ...... 23
IV. POLICY LETTER ...... 23 - ii -
ANNEXES Annex I Summary Development Effectiveness Matrix (DEM) Annex II Policy Matrix Annex III Results Matrix
REQUIRED ELECTRONIC LINKS (REL) REL#1 Policy Letter REL#2 Means of Verification REL#3 Monitoring and Evaluation Arrangements
OPTIONAL ELECTRONIC LINKS (OEL) OEL#1 Comparative Matrix OEL#2 Loan Proposal First Operation JA-L1080 OEL#3 References
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ABBREVIATIONS BFHI Baby-Friendly Hospital Initiative CCM Chronic Care Model DALYs Disability Adjusted Life Years DFID United Kingdom Department for International Development EBP Essential Benefit Package ECHO Extension for Community Healthcare Outcomes ESMR Environmental and Social Management Report ESS Environmental and Social Strategy FCTC Framework Convention on Tobacco Control FY Fiscal Year GDP Gross Domestic Product HIMS Hospital Information Management System HIV Human Immunodeficiency Virus IDB Inter-American Development Bank IMF International Monetary Fund IS4H Information Systems for Health JHLS III Jamaica Health and Lifestyle Survey LB Live Births MNDs Mental and Neurological Disorders MOHW Ministry of Health and Wellness NCD Non-Communicable Diseases NFITF National Food Industry Task Force NHI National Health Insurance NHIP National Health Insurance Plan NIR Nominal Interest Rate NMHAP National Mental Health Action Plan NSAP-NCD National Strategic and Action Plan for the Prevention and Control of Non- Communicable Diseases PAHO Pan American Health Organization PBL Policy-based loan PBP Programmatic policy-based loan POD Proposal for Operation Development PROMAC Programme for the Reduction of Maternal and Child Mortality SPF Safeguard Policy Filter SSF Safeguard Screening Form TCL Tobacco Control Legislation UNOPS United Nations Office for Project Services WHO World Health Organization YLLs Years of Life Lost
PROJECT SUMMARY JAMAICA SUPPORT FOR THE HEALTH SYSTEMS STRENGTHENING FOR THE PREVENTION AND CARE MANAGEMENT OF NON-COMMUNICABLE DISEASES PROGRAMME II (JA-L1086) Financial Terms and Conditions Borrower Flexible Financing Facility (a) Jamaica Amortization Period: 20 Years Executing Agency Disbursement Period: 1 Year Ministry of Finance and the Public Service (MOFPS) Grace Period: 5.5 Years (b) Source Amount (US$) % Interest rate: LIBOR Based Credit Fee: (c) IDB (Ordinary Capital 100,000,000 100 Inspection and supervision fee: (c) OC): Weighted Average Life (WAL): 12.75 years Dollars of the United Total: 100,000,000 100 Currency of Approval: States of America Project at a Glance Project objective/description: The objective of this Programme is to contribute to the improvement of the health of Jamaica’s population by strengthening comprehensive policies for the reduction of Non-Communicable (Chronic) Diseases (NCDs) risk factors and improved access to an upgraded and integrated primary and secondary health network in prioritized areas with an emphasis on chronic disease management, that provide more efficient and higher quality care. Within the overall programme, the specific development objectives of the second operation of the PBP are: (i) to promote regulatory and policy measures for the reduction of risk factors that cause NCDs; and (ii) to promote regulatory and policy measures to improve NCD early detection and clinical management. This policy-based loan (PBL) is the second of a programmatic PBL series, made up of two contractually independent and technically linked loans, as per document Policy-based Loans Guidelines for Preparation and Implementation (CS-3633-2).
Special contractual clauses prior to the first disbursement: The single disbursement of loan resources will be subject to the Borrower’s compliance with the policy conditions of the second operation summarized in the Policy Matrix (Annex II) and the Policy Letter (REL#1), as well as the compliance with the conditions contained in the loan contract (¶3.3).
Exceptions to Bank Policies: None. Strategic Alignment Challenges(d): SI ☒ PI ☐ EI ☐ Cross-Cutting Themes(e): GD ☒ CC ☐ IC ☒
(a) Under the Flexible Financing Facility (FN-655-1), the borrower has the option to request modifications to the amortization schedule, as well as currency, interest rate and commodity conversions. In considering such requests, the Bank will take into account operational and risk management considerations. (b) Under the flexible repayment options of the Flexible Financing Facility (FFF), changes in the grace period are possible as long the Original Weighted Average Life (WAL) and the last payment date, as documented in the loan agreement, are not exceeded. (c) The credit fee and inspection and supervision fee will be established periodically by the Board of Executive Directors during its review of the Bank’s lending charges, in accordance with the relevant policies. (d) SI (Social Inclusion and Equality); PI (Productivity and Innovation); and EI (Economic Integration). (e) GD (Gender Equality and Diversity); CC (Climate Change and Environmental Sustainability); and IC (Institutional Capacity and Rule of Law).
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I. PROJECT DESCRIPTION AND RESULTS MONITORING
A. Background, problem addressed, and justification
1.1 In November 2018, the Board of Directors of the Inter-American Development Bank (IDB) approved the hybrid operation for Jamaica including the first of two Programmatic policy-based loans (PBP) ‘‘Support for the Health Systems Strengthening for the Prevention and Care Management of Non-Communicable Diseases Programme (JA-L1080; 4669/OC-JA)’’ for US$50 million, and an investment loan for US$50 million (JA-L1049; 4668/OC-JA).’’ Additionally, in 2019, the European Union Caribbean Investment Facility (EU-CIF) approved a €10 million investment grant ‘‘Support for the Health Systems Strengthening for the Prevention and Care Management of Non-communicable Diseases Programme (JA-G1005; GRT/ER-17830-JA)’’ to improve the quality of primary care provided through health centers in the catchment areas of the hospitals selected for IDB investments, as well as patient adherence to chronic non-communicable diseases (NCD) management protocols. Together, the PBP, the investment loan and the investment grant comprise the “Support for the Health Systems Strengthening for the Prevention and Care Management of Non-Communicable Diseases Programme.”
1.2 This document proposes the approval of the second operation of the PBP series. The first operation of the series supported the formulation of regulatory frameworks aimed at reducing the risk factors for NCDs, and aligned health policies, guidelines, and protocols to manage NCDs efficiently. This second operation that completes the PBP consolidates the approval and implementation of the public health policies to reduce the risk factors and improve early detection and clinical management of NCDs.
1.3 Jamaica has concluded its tenure with the International Monetary Fund (IMF) reform agreement and has made significant progress towards achieving a stable macroeconomic environment and debt sustainability since 2013 under two IMF agreements. The country maintained strong economic performance in fiscal year (FY) 2019/2020, with macroeconomic stability anchored in prudent fiscal and monetary policies, as well as related institutional reforms. Particularly, Jamaica has consistently reduced its debt-to-GDP ratio to historic lows of 95%, increased the net international reserve (NIR) to US$3.2 billion as at the end of March 2020 and achieved an unemployment rate of 7.2% in October 2019, while maintaining a primary surplus for over two decades. However, these remarkable results are yet to significantly impact the nation’s growth, which has averaged approximately 1% per annum for the last 30 years [1].
1.4 Jamaica’s macroeconomic outlook is negative at this time, given the effects of the COVID-19 pandemic, with an expected decline of approximately 4%-6% for 2020. Inflation was 6.2% as at June 2020, which is above the inflation targeting range of 4% to 6%, with expectations of it returning within the band by end FY2020/2021 as spending decreases. Also1, in addition to the recently announced fiscal stimulus (by the Minister of Finance and the Public Service), the Government of Jamaica is
1 Ministry of Finance Press Release: https://mof.gov.jm/mof-media/media-centre/press/2633-fiscal-stimulus- response-to-the-covid-19.html.
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expected to invest approximately 1% of this year’s budget to the COVID-19 contingency fund for the response of the health system to the outbreak. This stimulus will serve as a cushion to the economy, providing individuals and corporations, most affected by the pandemic, with a fund package to offset basic expenditure for at least a quarter.2 Furthermore, capital expenditure directed towards transport, health and energy infrastructure (among others) are still underway, as well as further debt consolidation. Other fiscal stimuli announced for the FY 2020/2021 will complement ongoing structural and financial sector reforms to bolster inclusive growth. Moreover, the authorities remain resolute in the fight against crime, which continues to impede investment and growth. In this context, the Government of Jamaica was in a prudent position to achieve its medium-term objectives in accordance with the fiscal rule’s debt-to-GDP level of 60% by 2028,3 an energy grid composition of 20% renewable by 2030 and the modernization of the public sector by 2030. However, these projections predate the COVID-19 crisis, and it is likely that the resulting shock to Jamaica’s tourism sector will result in: (i) lower levels of output growth; (ii) lower- than expected government revenues; and (iii) higher public expenditure requirements for crisis mitigation and stimulus measures.4 In this context, we would expect the budget deficit to be higher than originally expected, and that financing needs—both domestic and external—would also be higher.
1. Demographics, health status and burden of chronic non-communicable diseases.
1.5 Jamaica is a middle-income country that in 2018 had 2.93 million inhabitants, with 0.5% annual population growth and a poverty ratio of 17.6%. The demographic transition is tangible with decreasing fertility and increasing ageing. The population is reaching replacement rate fertility (two births per woman), which means that the population growth is slowing down, which is visible in the population pyramid, where the base of children 0-5 is shrinking and the highest percentage is in age group 20-24 years. This demographic change in part is due to an increased access to contraceptives since 83.7% of reproductive age women have their contraceptive needs met. However, adolescent’s fertility rate (women aged 15-19) remains above global average (53 births versus 46 births per 1,000 respectively) [2] [3]). The average life expectancy is 77.5 years for women and 72 years for men, and 9.1% of the population is older than 65 years [4]. Jamaica has a higher life expectancy (74.6 years) than other Caribbean countries such as Guyana (67.7 years), Suriname (71.3 years), and Trinidad and Tobago (73.0 years) [5]. The projections indicate that by 2050, the proportion of older adults >65 years will reach 22%.
1.6 The country faces a triple burden of disease characterized by: (i) persistence of infectious diseases, and maternal, neonatal and infant mortality; (ii) an upward trend of accidents and interpersonal violence; and (iii) rising prevalence of chronic
2 The Ministry of Finance and the Public Service. Fiscal Stimulus Response to the Covid-19. Press Release https://mof.gov.jm/mof-media/media-centre/press/2633-fiscal-stimulus-response-to-the-covid-19.html. 3 International Monetary Fund. IMF Executive Board Completes Sixth and Final Review under the Stand-By Arrangement for Jamaica. Press Release 19/393. https://www.imf.org/en/Publications/CR/Issues/2019/11/07/Jamaica-Sixth-Review-Under-the-Stand-By- Arrangements-Press-Release-Staff-Report-and-48794. 4 The Ministry of Tourism. Press Release. The Recovery of Tourism must begin now. April 10, 2020. https://www.mot.gov.jm/news-releases/recovery-tourism-must-begin-now.
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non-communicable diseases (NCDs). The Ministry of Health and Wellness has ongoing public health actions to control infectious diseases. The primary concern is the COVID-19 pandemic that began on March 10th, 2020, with the first imported case identified in Jamaica and that by August 26th, 2020, it had reached 1,732 cases. The MOHW implemented public health measures to reduce the speed of the dissemination of the infection, such as social distancing, closed schools, quarantined several communities, and tested contacts. Also, it reinforced the supply capacity of 19 hospitals to satisfy the expected demand and trained health personnel on the care of the COVID-19 disease and its complications [6] Additionally, the Government of Jamaica implemented intersectoral actions led by the Office of Disaster Preparedness and Emergency Management to coordinates with governmental agencies and the private sector to respond to this threat. Regarding maternal, neonatal, and infant health care, the MOHW has the ongoing Programme for the Reduction of Maternal and Child Mortality with the support of the European Union to accelerate the decline of maternal and infant deaths [7].
1.7 Patients with COVID-19 that also have NCDs are at high risk of developing the more severe forms of the disease, require intensive care, mechanical ventilation, and 5% of COVID-19 patients develop severe complications, and most have chronic conditions. [8] An analysis of 49,698 patients with COVID-19 revealed that patients who developed severe complications had underlying NCDs such as hypertension, diabetes, respiratory, and cardiovascular diseases. Also, patients that are overweight, obese or smoke are designated at high-risk.[9] Currently there is no cure or vaccine for COVID-19 therefore, in addition to the current measures to contain the pandemic, it is justifiable to reinforce public health policies and health services to mitigate the risks for patients with NCDs. This operation addresses the risk factors that contribute to NCDs patients to be more susceptible, such as smoking. Also, modernizing the services through the introduction of the chronic care model and the digital information system will contribute to improve the capacity of healthcare services to identify undiagnosed patients with NCDs, provide better care to those under treatment and improve health outcomes. Better equipped facilities and NCDs patients receiving proper care reduce the risk of developing severe complications.
1.8 Chronic NCDs are the leading causes of ambulatory and hospital care and the top causes of disability and mortality. The most prevalent NCDs are overweight/obesity (54%); hypertension (33.8%) [10]; cancers (i.e., breast cancer incidence rate is 43.1 per 100,000 women) [11]; and diabetes (12%). Among, Mental and Neurological Disorders (MNDs), depression is the most frequent (14.3%), and dementia affects 5.9% of the population [12]. NCDs are the leading contributors to Disability Adjusted Life Years (DALYs) [13]. The high proportion of patients with NCDs place these conditions as the top causes of ambulatory and hospital care due to the need for lifelong and complex treatment. NCDs require a substantial amount of human, diagnostic and therapeutic resources. The goal of the management of NCDs is to help patients to keep their disease under control to reduce the risk of acute and chronic complications, decrease the cost of care and increase life expectancy. Uncontrolled patients develop acute and chronic complications more quickly than controlled patients, they are at most risk of disability and premature mortality and their costs of treatment is the highest. Metabolic control is a hard-to-reach goal without high quality and accessible care. The findings from the 2016 Jamaica Health and Lifestyle Survey (JHLS III) indicate that only 27.5% of patients with diabetes and 31% of patients with hypertension had blood glucose and blood pressure controlled [12].
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The leading causes of death are: (i) diabetes; (ii) stroke; (iii) interpersonal violence; (iv) ischemic heart disease; (v) chronic kidney disease; and (vi) HIV/AIDS [13]. NCDs have been escalating as the foremost causes of premature death. Between 1990 and 2016, the toll increased from 55.6% to 68.8% of Years of Life Lost (YLLs).5 Moreover, in 2016, NCDs accounted for 8 of the 10 leading causes of death and represented 85% of all deaths compared to 78.6% in 1990. The toll of deaths from NCDs has existed longer in Jamaica than in other countries of the region.6
1.9 The risk factors for NCDs that drive most of the morbidity, disability, and deaths are highly prevalent among the Jamaican population and represent a challenge for public health policies and programs. The primary risk factors are: (i) consumption of tobacco products; (ii) excessive consumption of alcohol; (iii) sedentary lifestyle; and (iv) unhealthy diet [12]. Population ageing is a risk factor for NCDs as well. These risk factors are sensitive to the same prevention and control measures that, if appropriately implemented through public health policies, have a positive impact on the population’s health, reduce the burden of disease and the cost of care. One risk factor in particular –exposure to childhood adversity (such as physical and sexual abuse, neglect, family violence or the death of a parent)– is related to later-life MNDs and a range of adult-onset NCDs. These chronic conditions disproportionally affect the most disadvantaged socioeconomic groups [14].
1.10 Consumption of tobacco products is widespread within the Jamaican population. The age-standardized prevalence of current tobacco smoking in people aged 15+ years is 18.2% for males and 4.4% for females, and the combined prevalence is 11.3%. Men 35-44 years old show the highest proportion (36%), compared to women (10%) [15]. The negative effect of tobacco consumption is visible in the high levels of respiratory conditions affecting men, with lung, larynx and trachea cancers, and respiratory diseases as the seventh and eighth leading causes of death, respectively. Also, tobacco consumption is associated with heart disease, stroke, and diabetes. Among pregnant women, it increases the risk of pregnancy complications, such as premature deliveries [16]. In 2003, the Framework Convention on Tobacco Control (FCTC) became the first international health treaty negotiated under the World Health Organization (WHO). FCTC includes evidence-based actions to reduce consumption and the harmful effects of tobacco. Jamaica ratified the FCTC in July 2005 [17].
1.11 The harmful use of alcohol results in a high risk of injuries and deaths in traffic accidents. Also, excessive drinking of alcohol increases the risk of cancer, suicide, liver cirrhosis and fetal malformations. Worldwide, 3.3 million deaths every year result from harmful use of alcohol (5.9% of all deaths) [18]. The 2016 National Drug Use Prevalence Survey reported that the prevalence of harmful use was 22.9% among men and 9.9% among women, whereas binge drinkers’ prevalence was 20.9% for men and 9.5% for women [15]. The age-standardized survival death rates of liver cirrhosis are 9.9 years for men and 5.0 years for women, and 48% of these deaths among men are alcohol-related [15].
5 YLLs give more weight to younger deaths than older deaths. For each death YLL is the difference between the life expectancy and the age of the person. Deaths that occur when a person lives longer than the life expectancy will generate zero years of life lost. 6 Institute for Health Metrics and Evaluation's -IHME, 2016.
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1.12 Unhealthy eating habits and lack of exercise are primary risk factors leading to overweight, obesity, hypertension, high blood glucose and abnormal blood lipids, proximate causes of NCDs [19]. From the maternal and child health perspective, women in reproductive age and pregnant women should have healthy dietary practices, that in turn reduce the risk of complications for the mother and the baby[20][21]. Moreover, breastfeeding and the proper introduction of complementary foods in the children’s first two years foster healthy growth and improve cognitive development, and have longer-term health benefits, like reducing the risks of NCDs later in life [22]. Unhealthy eating habits are visible in all age groups. Most of the Jamaican population (70%) does not have access to safe, adequate, or nutritious food. Only 38% eat vegetables daily, 26% eat fruit twice a day, while one-third drink sweetened beverages, and 10% consume salt in excess [12], these findings signal the need to promote healthy eating habits among consumers .
1.13 Physical exercise is not a routine part of the lifestyle of most Jamaicans. According to the JHLS [12], over 70% of men engage in moderate to high levels of physical activity, compared to only 38% of women. Approximately 40% of Jamaicans consider their work sedentary, and 90%, ages 15 to 74 reported being either sedentary or participating in light physical activity during their leisure time. Exercise contributes to the prevention of hypertension, overweight, and obesity, and is associated with a delay in the onset of dementia and improved mental health.
2. Health policies to reach universal access and increase public funding.
1.14 The MOHW is implementing nation-wide policies to expand access and deliver effective quality healthcare. The MOHW, with the support of the Bank [23], designed the Ten-Year Strategic Plan “Vision for Health 2030” to reach universal healthcare coverage. The Plan comprises the creation of a comprehensive essential benefits package (EBP), restructures the health services network, and consolidates the governance. Also, it proposes improvements in human resources and infrastructure [24][25].
1.15 The Jamaican national health system is tax based and further economic resources are necessary to satisfy the demand. The MOHW estimated that public financing should increase from 3.47% to 6% of GDP by 2030, and currently the green paper of the National Health Insurance Plan under public consultation has three central components: focus on funding through pooling of funds, a membership guarantee and entitlement modality, and definition of a basket of services. Currently the MOHW provides care at no cost to all the inhabitants, additionally, the National Health Fund [26] covers 28% of the population and 19% has private insurance. The National Health Fund (NHF) is the primary source of financing and access to medicines for NCDs patients in public and private sectors through (i) the NHF Card Programme (502,576 affiliates) that without age restriction receive subsidies for medicines for 17 NCDs.7 Also, the Jamaica Drug for the Elderly Programme Card (315,987 beneficiaries) has specific list of drugs at no cost to beneficiaries 60+ years
7 Asthma, arthritis, breast cancer & breast cancer receptor studies test, benign prostatic hyperplasia, diabetes & diabetes programme, epilepsy, glaucoma, high cholesterol, hypertension, ischemic heart disease, lupus, major depression, prostate cancer, psychosis, rheumatic fever/heart disease, sickle cell disease, vascular disease.
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with ten NCDs.8 Moreover, the NHF delivers in-patient and outpatient pharmacy services for the MOHW and support health-promotion programs to aid in the prevention, reduction, and management of NCDs and infectious diseases.
1.16 The Government of Jamaica is deliberating another initiative to reach universal coverage, which is the National Health Insurance Plan (NHIP) that is under public consultation [27]. The NHIP has three components: focus on funding through the pooling of funds, membership guarantees and entitlement modality, and definition of the EBP. The NHIP aims to provide appropriate levels of access, coverage, and financial protection to the population.
1.17 The patients with NCDs will benefit from these initiatives in terms of access to healthcare and financial protection. Increasing the funds for NCDs health care is critical because these conditions represent the most substantial toll of health expenditures; 15% of the health budget is allocated to care of diabetes, cardiovascular conditions, cancer, and chronic obstructive pulmonary disease. Jamaica can save US$640 million between 2017 and 2032 if it scales up the coverage of clinical interventions and implements policy measures to reduce tobacco and alcohol consumption [28], this amount represents 0.58% of Jamaica’s GDP. From the health policy perspective, the provision of universal health coverage should be accompanied by the reinforcement of primary care services to provide high-quality care. Best practices that comprise guidelines for early detection and treatment, the implementation of a chronic care model, and the digitalization of the health information system contribute to improving the capacity of the system and improve the health outcomes of NCDs patients, reduces disability, early mortality, and the costs of care.
3. Progress and challenges of public policies to address risk factors and provide care to patients with NCDs.
1.18 The Government of Jamaica, through the MOHW, is designing and implementing public health policies to mitigate the risk factors associated with NCDs such as reduction of the consumption of tobacco, alcohol, and unhealthy diets, promotion of physical exercise, and decrease of the prevalence of overweight and obesity. Also, it is modernizing healthcare for patients with NCDs. In particular, the formulation process for the alcohol and tobacco policies and the National Plan of Action for Information Systems for Health (NPAI) must be sent to the Cabinet to continue the policy cycle. After Cabinet’s approval, the GOJ has different paths for these policies to be approved and implemented. For instance, after Cabinet’s approval, it is necessary the creation of a green paper that must be subject to public consultation, in which the civil society and different stakeholders participate. Policies and programs such as Jamaica Moves or the National Plan of Mental Health are to be implemented through the health services and in the community. Whereas the National Food Industry Task Force (NFITF) already has the participation of different stakeholders.
1.19 Jamaica tobacco control policies require to be reinforced and further executed. The assessment of the implementation of the WHO Framework Convention on Tobacco Control (WHO FCTC), and the WHO Report on the Global Tobacco
8 Hypertension, cardiac conditions, arthritis, benign prostatic hyperplasia, high cholesterol, vascular disease, diabetes, glaucoma, asthma, psychiatric conditions.
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Epidemic published in 2019 [29] inform the advancements and gaps of the tobacco control measures. The country has made progress in meeting its obligation under the FCTC. Currently, there is a comprehensive ban on smoking in public places, whether indoor and outdoor. Also, the government implemented in full graphic warning and packaging requirements, public health regulations and taxes. However, to date, there is still no legislation regarding tobacco advertising, promotion, and sponsorship. Instead, several laws address specific means of advertising, such as a ban on tobacco advertising on domestic television and radio, and restrictions on outdoor advertising and brand marking. Moreover, it is necessary to implement stricter policies on information campaigns and treatments for smoking cessation. The Government of Jamaica updated its taxation on tobacco products policy aligned to the FCTC standards: from 2014/15 to 2017/18 the tax on cigarettes increased by 62%. However, the WHO recommends raising tobacco excise taxes so that they account for at least 70% of retail prices. Tobacco excise taxes in Jamaica are still below these recommendations. Moreover, tobacco taxes finance 20% of the National Health Fund.
1.20 Jamaica lacks a written national alcohol policy or action plan. The country has excise tax on alcoholic beverages, such as beer, wine, and spirits, and it set the national legal minimum age (18 years) for off-premise sales. It also has a legally binding regulation on alcohol advertising. Still, Jamaica lacks regulations on alcohol sponsorship and sales promotion and legally required health warning labels on alcohol advertisements.
1.21 The policies to reduce unhealthy dietary habits and encourage physical activity recognize the importance of healthy nutrition in the early years that produce essential health gains in older ages. To support better nutrition in childhood, the Government of Jamaica drafted the National Infant and Young Child Feeding Policy [30] that promotes the uptake of exclusive breastfeeding for the first six months of life, followed by adequate complementary feeding. Also, it ensures that all facilities providing maternity and child health services obtain accreditation in line with the Baby-Friendly Hospital Initiative (BFHI) [31]. There are challenges that might impede appropriate feeding practices, such as premature suppression of breast feeding and introduction of other beverages (tea, porridge) with less nutritional value, cultural preferences, women’s workload, and socioeconomic conditions.
1.22 In 2017, the MOHW launched the Jamaica Moves initiative to promote physical activity and educate on practical means of fostering healthier eating habits and promotion of routine checks targeting individuals across the lifespan. Jamaica Moves maintains an active multi-media educational campaign that comprises a website, TV and newspaper ads, brochures, posters and social media campaigns. In 2019, the program expanded to schools as a pilot program. However, Jamaica Moves requires technical support to develop medium-term strategic planning, and data-driven evaluations to ascertain its sustainability and effectiveness on promoting a healthy lifestyle.
1.23 An additional effort to tackle unhealthy habits is the creation of the National Food Industry Task Force (NFITF). This group is acquiring the support and participation of the food sector while ensuring coherence among the Government Ministries and adherence to evidence-based public health practices and recommendations to combat nutrition-related diseases. Amongst the Task Force objectives are:
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(i) regulations of food labelling; (ii) food marketing; (iii) product reformulation (i.e., reduce fat, sugar and salt content of industrialized food); and (iv) advocacy and communication to educate the public. Moreover, in January 2019, the MOHW implemented a ban on sugar-sweetened beverages in public schools and public health facilities. Currently, the decision on imposing taxes on sugary drinks is still pending. The successful examples of other LAC countries, such as Mexico [32], Barbados [33], and Bermuda [34], are relevant references. Interventions that comprise fiscal measures, food advertising and regulation, and food labelling generate health gains on adults shortly after their implementation. The benefits are faster for interventions that narrowly target high-risk individuals and age groups [35]. NFITF has some challenges, such as the resistance of the industry to modify some contents and label unhealthy foods at schools.
1.24 Access to timely and high-quality health information system remains a challenge in Jamaica and this also affects NCDs care negatively. NCDs require a digital health information system able to gather data and facilitate the processes of care such as screening, diagnosis, treatment and follow up of patients and facilitate communication between health providers and referral of patients. Also, the information system is needed to measure quality of healthcare and health outcomes. Currently the health information system is not able to satisfy the needs of the care of NCDs patients. The National Health Information System assessment performed in 2011 identified strengths, such as the valuable data sources (censuses and vital registration systems) and efficient monitoring of core health status. The evaluation also reported weaknesses, such as the inability to establish and maintain effective systems/procedures for stakeholder collaboration and participation, inadequate infrastructure, human resources and financing and weak reporting mechanisms [36].
1.25 In 2015, the MOHW published the 2014-2018 National Health Information System Strengthening and e-Health Strategic Plan with the vision of providing “…a single electronic health record for every person that facilitates patient safety, quality and continuity of care.” Some of the plan’s activities have been implemented, including the pilot of an open-source solution for Electronic Patient Administration.9 Also, it comprised the design and deployment of a pilot e-triage portal at the Bustamante Hospital for Children, which resulted in decreased waiting times. Another activity was the application of the Extension for Community Healthcare Outcomes (ECHO) telementoring portal,10 in ten facilities to improve the provider capacity to treat Human Immunodeficiency Virus (HIV) patients. Additional efforts are necessary to implement a robust digital health ecosystem for patients with NCDs. These activities are aligned with the NPAI that this operation is supporting.
1.26 Moreover, a significant number of challenges remain in terms of governance, infrastructure, infostructure and interoperability, and human resources for digital transformation. Jamaica's health information system needs to focus on critical foundational areas, such as formal governance structure, design of system architecture, and adoption of international standards for patient privacy, interoperability and disease classification. Incorporation of interoperability standards is critical for cost-effectiveness and efficiency because many health information
9 GNU Health is a Free and Open-Source Software (FOSS). 10 ECHO is a platform run by the University of New Mexico Health Sciences Center to develop the capacity to treat chronic, standard, and complex diseases in rural and underserved areas.
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systems are "digitally walled", preventing them from effectively exchanging information.11
1.27 Current paper-based system for clinical records and patient's appointments is outdated. The limited storage capacity of clinical records in health facilities makes security and safety of patient information a significant issue and impairs performing clinical audits efficiently. During 2017, the MOHW conducted the first stage of the Information Systems for Health (IS4H) assessment with the Pan American Health Organization (PAHO) support. The evaluation identified critical areas for building on previous work, in addition to the need to make strategic decisions regarding governance and assess the sustainability of the current approach to reach the MOHW's vision. In 2019, IDB conducted an analysis with the MOHW to assess the level of maturity of the electronic clinical history; the results signaled that it is in the early stages. The maturity model measures the progress of digital transformation in five dimensions: people and culture, health information, infostructure, infrastructure and governance and management. In the five dimensions, the MOHW reaches a score of 1 on a scale of 0 to 5. IDB, PAHO and Global Fund are working together to support the MOHW to implement the IS4H strategic Plan and blueprint. Additional support is required to surmount structural challenges.
4. Programme strategy.
1.28 The Government of Jamaica developed the National Strategic and Action Plan for the Prevention and Control of Non-Communicable Diseases (NSAP-NCD) to reduce the burden of preventable morbidity and disability and avoidable premature mortality due to NCDs and injuries by 25% by 2025. The plan covers: (i) cardiovascular diseases; (ii) cancer; (iii) chronic respiratory diseases; (iv) diabetes; (v) sickle cell disease; (vi) mental health; and (vi) injuries. One of the priority areas is the provision of comprehensive and integrated disease management for NCDs and injuries. In congruence with this plan, the first operation prioritized the development of the public policies, regulations, and technical standards requiring approval by the MOHW or the Cabinet aimed at tackling the risk factors in the general population and set the groundwork to strengthen the capacity to screen and manage NCDs patients. The second operation will foster the implementation of public health policies to reducing exposure to modifiable risk factors for NCDs and promoting health throughout the lifecycle. Also, it will strengthen and reorient health services to address the prevention and control of NCDs through people-centered primary health care services that entail a NCDs' screening program, innovative model of care able to provide high-quality treatment. Moreover, the second operation furthers the policies and regulatory foundations to digitalize the health information system.
1.29 To reduce the prevalence of tobacco usage, the Tobacco Control Legislation (TCL) must be consistent with the obligations under FCTC. The first operation of this programmatic policy-based series promoted the drafting of the Bill of TLC. The next steps to complete this policy process after assuring that the contents of the draft Bill met the policy objectives consist of submitting the draft Bill to the Legislation Subcommittee of Cabinet for approval for the tabling of the Bill in Parliament. This process is being accompanied by the interaction of the MOWH with different
11 Health Information Systems Interoperability Maturity Toolkit: Users' Guide, 2017.
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stakeholders, from the Government and the private sector, to endorse Jamaica’s national position on tobacco control as a high priority in the NCDs agenda.
1.30 The Government of Jamaica is promoting the development and implementation of evidence-based strategies for the prevention and control of harmful alcohol consumption. The ongoing construction of the National Policy for Reduction of the Harmful Consumption builds on laws, regulations, and existing initiatives in Jamaica. The policy comprises ten actions: (i) alcohol pricing and taxation; (ii) reducing physical availability of alcohol; (iii) controlling the marketing of alcoholic beverages; (iv) drinking driving policies and countermeasures; (v) controlling drinking by youth; (vi) reducing negative consequences of drinking and intoxication and promoting law enforcement; (vii) reducing the health impact of illicit and informally produced alcohol; (viii) enhancing the health services response; (ix) promoting awareness and education on crucial alcohol issues; and (x) enhancing capacity and stimulating community action on alcohol issues. The construction of this policy sets the groundwork to develop an actionable plan and identifies the key stakeholders and their roles. It also suggests areas where new or revised regulations or legislation will be needed and potential monitoring and evaluation activities.
1.31 The ‘‘Jamaica Moves’’ embraces the Ottawa Charter for Health Promotion and creates a sustainable behavior change model to tackle NCDs risk factors. It promotes activities that make conditions favorable for behavior change through advocacy for health. Moreover, it provides access to information that enables all people to reach their fullest health potential. This program cuts across all sectors of society, targeting at the individual, interpersonal, organizational, community and national levels. Jamaica Moves employs a settings approach focusing on schools, workplaces, and communities.
1.32 The National Infant and Young Child Feeding Policy (NIYCP) facilitates and establishes standards for the promotion of protection and support for breastfeeding. It also creates a sustainable environment to reduce infant morbidity and mortality and improves health and nutrition. In December 2019, the MOHW launched the NIYCP island-wide with 38 support groups, healthcare staff, Parish Infant and Young Child Feeding Committees, and Hospital Infant Committees.12 The NIYCP has several aims: (i) to increase breastfeeding in communities and workplaces; (ii) to achieve the status of Baby-Friendly Hospital Initiative (BHFI) in maternity and childcare settings; (iii) to establish mechanisms to collect information and defining indicators of feeding practices for infants and children; and (iv) to build the capacity of healthcare services and community to promote breastfeeding and developing public education initiatives to support best feeding practices for infants and children.
1.33 The MOHW is working to improve the competency of healthcare services for NCDs. The characteristics of NCDs support this decision. NCDs are complex conditions that place similar demands and require skilled health providers, have comparable requirements that prompt to organize care through interprofessional teams, and share common primary and secondary risk factors amenable to interventions [37]. In this regard, the reinforcement of the competency of healthcare services involves the introduction of a model of care suitable for NCDs. The chronic care model (CCM)
12 MOHW, Press release. National Infant and Young Child Feeding Network. https://www.moh.gov.jm/national- infant-and-young-child-feeding-network-niycfn-launched/.
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[38] emphasizes a gender-sensitive approach that addresses the different manifestations of the diseases, prevalence, health-seeking behavior, and feasibility of complying with treatment according to gender. Also, the CCM is congruent with the trajectory of the NCDs that require guidelines for screening, treatment, and nutritional management. Figure 1 provides a comprehensive overview of the CCM components.
Figure 1. The Chronic Care Model
Health systems Community Organization of health care
Resources Self- Clinical and Policies Information management Delivery Decision Systems Support System Support Design
c Informed Prepared, Productive Proactive activated interactions patient Practice team
Improved outcomes
Source: Pan American Health Organization. Innovative Care for Chronic Conditions: Organizing and Delivering High Quality Care for Chronic Noncommunicable Diseases in the Americas. Washington, DC: PAHO, 2013. 1.34 The Government of Jamaica is working to fulfil the objectives of the WHO Mental Health Action Plan and agreed to the program policy goal of developing the National Mental Health Action Plan (NMHAP) to guide the reform of mental health services. The NMHAP strengthens leadership and governance in mental health, as well as mental health promotion, mental illness prevention and rehabilitation and management. The Government of Jamaica continues restructuring mental health services to keep the patients away from a long-term hospital stay and receive care at community-based residential living facilities and health care settings able to accommodate short-stay inpatient and outpatient care services.
1.35 The MOHW has a NPAI that will introduce the digitalization of the health information. It will include interoperability standards across components of information systems to facilitate tracking of patients throughout the public health sector, a referral system, modules to support NCDs self-management and follow-up appointments, and telemedicine and telehealth initiatives. Also, the program comprises the implementation of the policy and legal framework workstream of the NPAI to govern
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the collection, use and disclosure of personal health information, whether it exists on paper or other formats.
1.36 Health information systems are critical for the provision of primary and secondary care for patients with NCDs. The WHO espouses the need for information systems for health as part of the Package of Essential NCDs Interventions for Primary Health Care in Low-Resource Settings [39]. Digital tools contribute to chronic care provision when patients and providers to share information, compare this information to evidence-based standards, and monitor results through regular feedback and interaction [40]. Health information technology has contributed to reducing mortality rates of patients with complex conditions whose diagnoses require cross-specialty care coordination and extensive clinical information management in hospital settings [41] [42], and improvements in resource allocation efficiency [43]. Moreover, health information systems have the potential to evaluate and improve clinical practice by reducing staff errors, improving automated harm detection, monitoring infections more effectively, and enhancing the care continuity during physician handoffs. The Hospital Information Management System (HIMS) has the potential to reduce waste and allow more efficient use of resources in the health system.
1.37 Telemedicine and mobile health (mHealth) improve the effectiveness and efficiency of NCD management [44] [45]. For example, blood pressure control consultations by way of 10-15 emails and phone calls can occur across weeks, and the cost is approximately 29% of the cost of in-person acute care [46]. mHealth tools, such as text messages, medication reminders, symptom monitoring, and educational resources facilitate patient-provider communication to increase adherence. Moreover, mHealth reduces the burden of traveling to a care provider to low-income patients, the elderly, and those living in rural areas. These tools also facilitate better management and improve patient confidence to monitor chronic diseases. Telehealth or the remote diagnosis and treatment of patients through telecommunications technology has been especially useful in the management of chronic diseases and has demonstrated improvement in outcomes (diabetes), empowerment and self-management (diabetes and high-risk dialysis patients) [47]. As mobile-cellular subscriptions are high in Jamaica (115 per 100 inhabitants) mHealth and telemedicine may provide an opening to improve patient adherence and aid in the follow-up. Jamaica has experience using ECHO’s telementoring portal for HIV patients. It is feasible to expand this platform and to pilot the use of mHealth and telemedicine for chronic care.
1.38 The MOHW is incorporating gender considerations in the strategies to combat NCDs. Biological differences and gender roles determine the type of access and health- seeking behavior of health services by men and women. These factors affect the incidence, manifestations, and consequences of NCDs. Developing effective treatments requires that health systems can analyze the gender determinants and the different associated risk factors [19]. The program incorporated this perspective by identifying gender differences in risk factors and disease prevalence and signaling the need to employ a gender-sensitive approach in policy formulation and prevention and screening efforts. 5. Programme logic: Summary of policy reforms. 1.39 For the Policy Matrix of the PBP, the Government of Jamaica and the Bank identified essential policies to reduce the risk factors of NCDs and improve clinical
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management and care of NCDs, considering the processes and timeframe of such policy measures and the duration of the PBP series.
1.40 In summary, the first operation supported policies and regulations that allowed the development of a coherent and comprehensive strategy to address NCD risk factors and clinical management of NCDs by the MOHW. The second operation will further support the approval and implementation of such policies and regulations, which, in turn, will contribute to mitigating the NCD burden. Further progress will be contingent on effective population behavior change to attain healthy lifestyles, which is supported by both operations, and the continued strengthening of the integrated health network approach with dependable primary health care.
1.41 The policies addressing the risk factors and reinforcing the clinical management of NCDs face several challenges (¶1.19 to ¶1.27) that require the government to take additional actions. Some of the medium-term activities to address the challenges are the following: (i) to increase and sustain the fiscal space to allocate resources to support the operationalization of the policies into programs and interventions; (ii) to reinforce the government’s capacity to minimize the possible interference of the alcohol, tobacco, and food industry to integrate intersectoral coalition activities; (iii) to gain advocacy of other sectors outside the MOHW since, by nature, public health policies are intersectoral; (iv) institutional capacity building to gather data to evaluate the outcomes and impact of the different policies; and (v) political advocacy to maintaining the policy cycle to design, implement, evaluate and redesign to improve the policies.
1.42 The perspectives on the sustainability of the public health policies, programs, and activities of this Programme are critical. The GOJ should increase its capacity to maintain the policies and programs and its benefits over time. The Programme is contributing to sustainability through several components: (i) demonstrating its effectiveness through the impact indicators in the results matrix; (ii) it sets the basis for monitoring progress over time through the implementation of the digital health information system; and (iii) it promotes training and capacity building through improving the competence of health personnel after implementing the screening guidelines, protocols, and chronic care model. However, these actions should continue to enable the healthcare system to keep up with the growing demand of patients with NCDs. The 10-year Strategic Plan and the initiative to provide universal health insurance might contribute to the sustainability of the policies and interventions.
1.43 The additionality of the Programme comes from coordinating critical policy design and implementation interventions at the population level (first component of the programmatic policy-based loan), at the clinical management level (second component), and the functioning of integrated health networks (supported with the investment operation). The Bank´s added value arises from its experience in working in strengthening health networks through many operations throughout the region for example ‘‘Strengthening health management in the State of São Paulo’’ (3051/OC-BR); ‘‘Strengthening Unified Health System in São Bernardo do Campo’’ (3400/OC-BR); ‘‘Multiphase Primary Health Care Program for Managing Chronic Noncommunicable Diseases’’ (3772/OC-AR); and the Mesoamerica Health Initiative, ‘‘Modernization of Infrastructure and Management of Hospitals - Western Region’’ (3306/BL-NI); ‘‘Community Health Program for Rural Municipios’’ (3696/BL-NI);
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‘‘Program to Support Health Sector Reform’’ (4030/BL-HO); and ‘‘Integrated Health Program II’’ (3608/OC-ES). 6. Alignment with health operations in execution 1.44 The health portfolio in Jamaica is addressing the reduction of NCDs burden comprehensively. In addition to the PBP policy reforms, the investment loan under execution (4668/OC-JA) and the investment grant of the European Union (GRT/ER-17830-JA) are bolstering the capacity of the MOHW to care for NCD's patients. These projects synergize with each other to reorganize and consolidate the health services to become healthcare networks that have competent and efficient primary care and hospital services. The interventions comprise improvements in management, proficiency, and quality of care through replacing three clinics, retrofitting seven clinics, and expanding the capability of three hospitals with new infrastructure, organization, and equipment. These improvements will facilitate the introduction of the chronic care model. Moreover, these operations are going to further the implementation of the policies of this second PBP operation.
1.45 Bank experience. In parallel with the first PBP operation and the ongoing investment operations, the Bank is supporting the MOHW through several technical cooperation projects. The TC “Improvement to Health Service Delivery” (ATN/OC-16573-JA) and the TC ‘‘Strengthening Health Systems in Jamaica’’ (ATN/OC‑14953‑JA) supported the strategic planning, the primary care renewal process, and financing strategy development. The ‘‘Energy Management and Efficiency Programme’’ (3877/OC-JA) aims at implementing energy conservation methods in Government facilities, including four hospitals. The TC ‘‘Support of the Strengthening of Public Health, Primary Care Services and Information Technology Strategies to Address Non-Communicable Chronic Diseases’’ (ATN/OC-17804-JA) is supporting the development of the plan to implement the CCM, and the design of quality of care indicators that will use the clinical information of the electronic health record of patients with NCDs.
1.46 Lessons Learned. The design of this operation considers lessons learned from PBL operations in the health sector. For instance, the Management Modernization for Universal Health Coverage Program I (3586/OC-PE) is supporting the preparedness and modernization of the Peruvian government through improving the managerial capacity of the MOH to achieve universal coverage. This PBL contributes with the Peruvian MOH to expand universal health coverage for the most vulnerable. The implementation of successful policies translates into health services improvement. The enhancement of preventive care services at the Family Health Community Teams in El Salvador increased the demand in primary care settings, reduced hospitalization of sensitive conditions to primary care services, and improved health outcomes (Integrated Health Program II 3608/OC-ES). In Argentina, the Program for Strengthening and integration of Health Networks in the Province of Buenos Aires (4821/OC-AR) aims at improving the delivery capacity and quality of primary, secondary, and tertiary public health services. The design and implementation of the components of the present PBP series take advantage of the positive outcomes of the operations mentioned earlier to expand access, improve preventive care and reinforce the capacity of the services. Moreover, the present PBP takes advantage of the modern and comprehensive perspective of public health [48] that addresses specific interventions at three levels: (i) society level where public health policies change the context and individual behavior (i. e., policies to reduce alcohol and
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tobacco consumption); (ii) community level through activities that local institutions deliver (i.e., Jamaica Moves program); and (iii) individual level through the provision of screening, diagnostic and therapeutic services (i.e., screening guidelines for diabetes and hypertension). These interventions have proven to be effective if accompanied by the strengthening of primary care services, such as the operations previously mentioned (3608/OC-ES and AR-O0013). The combined effect of public policies to tackle risk factors reduce by 25% the mortality of cardiovascular disease [49], and the impact of promoting exercise and a healthy diet is cost-effective to reduce overweight and obesity in school children [48]. The analysis of the effectiveness of the chronic care model in primary care settings for diabetes management translates into better health outcomes that reduce the demand of emergency services and hospital admissions [50].
1.47 Strategic alignment. This second PBP operation is consistent with the Second Update of the Institutional Strategy (AB-3190-2). Also, it is in line with the development challenges of Social Inclusion and Equality by improving access of the population to health care services. This second operation is also aligned with the cross-cutting themes of: (i) Gender Equality and Diversity, by being able to increase access to men and women to public health policies and healthcare services focused on diseases that affect them disproportionately, and (ii) Institutional Capacity and Rule of Law, by being able to improve the quality of public health services and policy formulation and implementation. Moreover, the Programme will contribute to the Corporate Results Framework (CRF) 2020-2023 (GN-2727-12) by expanding the number of beneficiaries receiving health services. It is consistent with the Health and Nutrition Sector Framework’s (GN-2735-7) priority to ensure that all people have timely access to quality health services, and with Social Protection and Poverty Sector Framework Document (GN-2784-7), as it promotes social inclusion by increasing access and quality of social services to the most vulnerable populations. Furthermore, it contributes to the objective of the IDBG Country Strategy with Jamaica 2016-2021 (GN-2868) to improve the public health system and achieve an increase in the usage of primary care facilities and a reduction in risk factors and the burden of NCDs and it is included in the 2020 Operational Program Report revised version (GN-2991-1).
1.48 Closing the health gender gaps. The PBP series contributes to addressing the gender gaps in the most critical health problems for men and women of different age groups. For instance, girls that have unhealthy lifestyles are at risk of overweight and of developing early NCDs such as diabetes and asthma. Women in reproductive age and those pregnant who smoke and drink in excess or are overweight or obese are at risk of premature deliveries and their offspring to congenital anomalies. Among women >50 years, breast and cervical cancer are the top causes of death, and dementia affects more often women than men. As for men, policies also address the different age groups. Boys and young males are more exposed to tobacco and alcohol and have more risk of accidents and violence than girls. Adult men and older adults are at risk of developing NCDs, such as diabetes, cardiovascular conditions, and cancer. The actions that support to bridge the gender gaps comprise public health policies to address the primary risk factors, and implementation of the chronic care model that entails differentiated screening guidelines and care protocols. Also, it comprises the basis for the modernization of the health information system to produce health data differentiated by age and sex. The impact indicators in the results matrix indicate that the evaluation will differentiate by age and sex the mortality rates
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of cerebrovascular accidents, premature mortality due to diabetes and hypertension, the prevalence of diabetes and hypertension, and obesity.
1.49 Donor coordination. The present operation complements and strengthens the operation of other multilateral donors. In 2019, the European Union Caribbean Investment Facility (EU-CIF) approved a €10 million investment grant (GRT/ER-17830-JA). The objective of this operation is to improve the quality of primary care provided through health centers in the catchment areas of the hospitals selected for the ongoing investment loan (4668/OC-JA) as well as facilitate patient adherence to NCD management protocols.
B. Objective, components, and cost
1.50 Objective. The objective of this Programme is to contribute to the improvement of the health of Jamaica’s population by strengthening comprehensive policies for the reduction of Non-Communicable (Chronic) Diseases risk factors and improved access to an upgraded and integrated primary and secondary health network in prioritized areas with an emphasis on chronic disease management, that provide more efficient and higher quality care. Within the overall programme, the specific development objectives of the second operation of the PBP are: (i) to promote regulatory and policy measures for the reduction of risk factors that cause NCDs; and (ii) to promote regulatory and policy measures to improve NCD early detection and clinical management.
1.51 This programme is the second of a PBP series, which is constituted by two contractually independent and technically linked loans, as per document Policy-based Loans Guidelines for the Preparation and Implementation (CS-3633-2). The policies in the PBP series will consolidate regulatory measures to address the preventable causes of NCDs and to reorient health systems to address prevention and control of NCDs through a people-centered primary health chronic care model (Annex II).
1.52 Component 1. Macroeconomic stability. The objective is to maintain an appropriate macroeconomic policy framework consistent with the program’s objectives and in accordance with the provisions of the Policy Letter and the Policy Matrix (Annex II).
1.53 Component 2. Reduction of risk factors that cause NCDs. The policies in this component address the four top avoidable risk factors associated with NCDs: tobacco, excess of alcohol consumption, unhealthy diets, and lack of adequate physical activity.
1.54 To reduce the prevalence of tobacco usage (policy condition 2.1), the Tobacco Control Legislation (TCL) is consistent with the obligations under FCTC. The first operation supported the Cabinet´s decision to write the TCL. The second operation will promote the submission of the TCL to Cabinet that it will include: (i) the regulation of interactions of Government of Jamaica officials with the tobacco industry to ensure that Government of Jamaica bodies interact with the industry only when and to the extent necessary to regulate the industry effectively; (ii) regulation of price and tax measures on all tobacco products so that these taxes are mandatory and need to maintain basic levels to reduce consumption; (iii) the full and mandatory prohibition
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on tobacco advertising, promotion and sponsorship, including a ban on point-of-sale tobacco displays (policy condition 2.1a) and (iv) compliance with the Protocol to Eliminate Illicit Trade on Tobacco Products. Moreover, approval by Cabinet for accession to the WHO FCTC protocol to Eliminate Illicit Trade in Tobacco products (policy condition 2.1b). The policy condition 2.1b changed from the original condition because the technical and policy approval processes are within the control of the Government of Jamaica and these arrangements must precede the ratification by WHO of the FCTC protocol. The WHO ratification is external to the Jamaican government. The MOHW continued the arrangements with the Ministry of Foreign Affairs and submitted to Cabinet the request of the approval for accession to the Protocol.
1.55 The Policy for the Reduction of Harmful Use of Alcohol will be developed and approved by the MOHW and submitted to Cabinet. The policy is in line with WHO guidelines and best buys13 regarding advertisement and sponsorship, availability, and pricing. The first operation supported the development and approval by the MOHW of the Concept Paper for the Reduction of Harmful Use of Alcohol Policy. The second operation will support MOHW approval and submission to Cabinet of this policy (policy condition 2.2). The modification of this policy condition is to indicate the proper policy procedure within the government. The original condition mentioned that the MOHW approved and submitted to Cabinet a Green Paper for the reduction of harmful use of alcohol. The correct procedure is that the Ministry elaborates and approves the policy proposal and sends it to the Cabinet for approval, once approved, it becomes a Green Paper.
1.56 A plan within Jamaica Moves at School Initiative will be developed, approved and implemented to promote healthy eating habits, physical activity and age-appropriate health check-ups.14 It will include provisions to limit the availability of sugar content of beverages offered at school; measures to facilitate increased physical activities amongst students; and measures to strengthen capacity at schools to identify and respond to at-risk students for NCDs. The first operation supported the development and approval of the plan, while the second operation will support its implementation that will be measured through the institutionalization of the measures in at least 50% of targeted schools (policy condition 2.3.).
1.57 An Infant and Young Child Feeding Policy and Strategic Plan will be approved and implemented to reduce malnutrition in infancy and childhood. The policy includes measures that address deficiencies and obstacles experienced in infant and young child nutrition and to provide the context for the development of innovative approaches to influence the determinants of nutritional behavior, including exclusive breastfeeding during the first six months of an infant’s life, adequate complementary feeding, support to the mother and the Baby-Friendly Hospital Initiative. As part of the first operation, the MOHW approved the policy and submitted it to Cabinet and the second operation will support the early implementation of the policy in crucial areas such as BFHI accreditation, the establishment of community support groups and
13 The World Health Organization (WHO) defined as” best buys” set of affordable, feasible and cost-effective intervention strategies for NCDs. The actions to reduce alcohol and tobacco consumption, increase physical activity and promote healthy diets” along with interventions to screen and manage cancer, diabetes and cardiovascular conditions are among the “best buys. 14 Jamaica Moves in Schools initiative began as a pilot intervention in 33 schools across the parishes of Kingston and St. Andrew, St. Thomas, and St. Catherine.
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certification of key personnel as Community Infant and Young Child Feeding Support Group Facilitators (policy condition 2.4).
1.58 To promote healthy eating and to provide useful, actionable, and timely information the second operation of this PBP series will support the implementation of a social media campaign to promote behavioral change to improve eating habits (policy condition 2.5). This component is supporting the implementation of the National Food-based Dietary Guidelines.
1.59 Component 3. NCD early detection and clinical management. This component includes regulatory and policy measures to improve the management of NCDs.
1.60 A CCM Concept Paper and Policy for the risk factor reduction, early detection, treatment, diagnosis and support for cardiovascular disease, diabetes, cervical, breast, prostate and colorectal cancer, depression and asthma will be developed to strengthen the delivery system design for priority NCDs care. The CCM will emphasize a gender-sensitive approach to the prevention, diagnosis, and treatment of NCDs. The CCM also prioritizes the importance of training health personnel in the gender determinants, that influence NCDs and barriers to care, and addresses the different manifestations of the disease, prevalence, health-seeking behavior, and feasibility of complying with treatment according to gender. The first operation supported the development of the CCM Concept Paper and Policy, and the second operation will support the implementation plan for at least one health network (policy condition 3.1).
1.61 Screening guidelines for the primary health care level will be developed and implemented to promote early detection of priority NCDs. The first operation supported the drafting of a concept paper for the development of the screening guidelines. The second operation will include the approval and implementation plan of the guidelines that will be piloted in at least one network (policy condition 3.2).
1.62 The Programme will support the development, approval, and publication of guidelines for the nutritional management in the delivery of obesity, diabetes, hypertension and cancer in hospitals and health center settings to improve the decision-making in the delivery of NCDs care. The guidelines will include the development and implementation of the dietary care plan based on nutritional adequacy, caloric control, nutrient density, variety and balance, and the individual anthropometric, biochemical, clinical and nutritional data. Moreover, the guidelines comprise the evaluation, documentation and monitoring of nutritional care, directives for self-management and indications for referrals. The first operation supported the development of the nutritional guidelines, whereas as part of the second operation, the MOHW will approve and publish on-line the guidelines (policy condition 3.3).
1.63 To strengthen Jamaica´s record on providing mental health services in community- based settings and of mental health promotion and prevention strategies, the programme will support the development and approval of the National Strategic Plan on Mental Health. The first operation supported the development of the plan, and the second operation will support the approval of the plan by the MOHW to provide comprehensive and community-based mental health promotion and prevention activities (policy condition 3.4).
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1.64 To provide the foundational elements for Information Systems for health, a National Plan of Action for IS4H (NPAI) will be developed. The IS4H plan includes elements to bolster interoperability standards across components of information systems to facilitate tracking of patients throughout the public health sector, a referral system, modules to support NCD self-management and follow-up appointments, and telemedicine and telehealth initiatives. The first operation supported the development of the plan of action and the second operation will support the submission to Cabinet for approval of the NPAI (policy condition 3.5a).
1.65 The NPAI requires the development and implementation of a policy and legal framework workstream. The first operation supported the development of the policy to govern the collection, use and disclosure of personal health information, whether it exists in paper or other formats. The implementation of the policy guidelines on PHIP operationalizes the Data Protection Bill and the Personal Health Information Protection (PHIP) (policy condition 3.5b). There was a modification in the wording of this policy condition to express better that the operationalization of this policy translates into the actual implementation of the policy guidelines on PHIP, the modification does not change the scope of the policy condition.
C. Key results indicators
1.66 The Programme will have three sets of indicators. The primary indicators will track progress in reducing the prevalence of diabetes, hypertension and premature mortality associated with NCDs. The second set of indicators will inform of the achievement of the targets related to the prevalence of risk factors (i.e., tobacco use, alcohol consumption). The third set of indicators will measure the performance of the chronic care model within the health networks and health facilities. 15 The health centers indicators comprise access to care with the visits to population ratio, waiting times and proper management of diabetes. Hospital indicators include the length of stay, readmission rates, and timely access to accident and emergency services. These indicators will measure the combined results of the investment and policy components of the Programme.
1.67 Beneficiaries of the programme. Direct and indirect beneficiaries of the Programme. This PBP series will benefit the Jamaican population at large, which comprises 2.9 million people due to the positive social effects identified in the programme. Tobacco and alcohol have benefits for all people. Jamaica Moves Program and Infant and Young Child Feeding Policy and Strategic Plan benefit mostly infants, young and school-age children that represents 24% of the total population. In contrast, the chronic care model will attend almost 50% of the people, mainly those who are overweight, obese or have diabetes or hypertension. Also, the National Strategic Plan on Mental Health will cover primarily adult population, about 50% of the total population.
1.68 Economic analysis. Based on OVE recommendations in its review of Evaluability of Bank Projects in 201116 and in the results of the review of evaluation practices and standards for policy reform support loans carried out by the Evaluation Cooperation
15 Annex III (Results Matrix) includes a section with specific output indicators for this second PBP operation. 16 RE-397-1: Currently, the score for the economic analysis section is calculated using the maximum value of the cost-benefit analysis and the analysis of cost-effectiveness. However, these analyzes analyses cannot be applied to loans in support of policy reform.
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Group (ECG), consisting of the Independent Evaluation Offices of Multilateral Development Banks),17 stated in paragraph 1.3 of document GN-2489-5 (Review of the Development Effectiveness Matrix for Sovereign Guaranteed and Non Sovereign Guaranteed Operation) that, among others, indicate that it would not be necessary to include an analysis of efficiency in the use of financial resources18, it was determined that an economic analysis will not be carried out for this type of loan as reported to the Bank's Board. Therefore, this operation does not include an economic analysis and such analysis was not considered for purposes of measuring the evaluability score in the DEM of this Programme.
II. FINANCING STRUCTURE AND MAIN RISKS
A. Financing instruments
2.1 This operation has been structured as a PBP and corresponds to the second operation of a programmatic series that consist of two contractually separate but technically linked loans, consistent with document CS-3633-2 on the preparation and implementation of PBPs. The programmatic approach was selected to: (i) provide medium-term support to the government’s program of fiscal policy reforms; (ii) promote ongoing dialogue; and (iii) facilitate the monitoring and refinement of the implementation strategy, give the highly complex nature of the reform involving policy actions at various levels of government. The amount of financing for this second operation of the programmatic series will be up to US$100 million, which will come from the Ordinary Capital (OC) resources.
2.2 Loan dimensioning. In accordance with the provisions of paragraph 3.27 (b) of the document (CS-3633-2)”, the dimensioning of the operation was performed based on the needs of fiscal resources facing the country. In November 2019, Jamaica's gross financing requirements for FY 2020/2021 were estimated to be about J$183.4 billion, equivalent to 8.1% of GDP, mostly caused by principal repayments (the overall budget surplus is estimated at 0.64% of GDP). About two-thirds of this financing was expected to come from domestic sources. The amount of this operation is equivalent to J$15,01 billion19 and will contribute to required external, official financing.
B. Environmental and social risks
2.3 Pursuant to Directive B.13 of the Environment and Safeguards Compliance Policy (OP-703), this program does not require an ex-ante classification of impacts. The operation supports the determination of policies, standards, management instruments, and other institutional strengthening actions, and therefore, no significant direct impacts are anticipated on the environment and natural resources.
17 Good Practice Standards for the Evaluation of Public Sector Operations. Evaluation Cooperation Group, Working Group on Public Sector Evaluation, 2012 Revised Edition. February 2012. 18 According to the ECG, PBPs should be evaluated according to relevance, effectiveness, and sustainability. Efficiency was not included as a criterion, given that the dimensioning of the PBP is linked to the financing gap of a country, being independent of the benefits of the project. 19 Exchange rate 150.10 date August 28th, 2020.
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C. Fiduciary risk
2.4 There are no fiduciary risks envisaged with this operation as the resources of this operation will be disbursed directly to the Consolidated Fund of the Jamaica, held under the custody of the Ministry of Finance and the Public Service, (MOFPS). These resources will be used to cover the project related financial needs of the Government of Jamaica.
D. Other key issues and risks
2.5 There are several risks involved with the reforms. The development and implementation of the policies to reduce risk factors, such as alcohol, tobacco, and unhealthy food consumption, face risks of being implemented. The potential risks of Public Management and Governance are: (i) problems of coordination and information sharing among institutions that might delay the compliance of the conditions that require such interaction; this risk is classified as medium. The means of mitigation for this risk is to follow‑up on the progress of the fulfillment of the policy conditions through follow up meetings with corresponding authorities from the different governmental branches: MOHW and MOFPS; (ii) another risk is the delays in the approval processes within the MOHW and different Ministries and Cabinet that would affect the compliance of the conditions; this risk is classified as medium. The means of mitigation is that the steering committee will follow up on the observance of the policy conditions through regular meetings; (iii) if there is a low perception of ownership within the MOHW, behavioral change may not occur as expected, reducing the possibility of achieving the Programme objectives; this risk is classified as medium high. The means of mitigation for this risk is a high-level sponsorship and internal promotion of the project; (iv) if there is little information sharing between MOHW and MOFPS, coordination may be lacking, resulting in low-quality products; this risk is classified as medium high. The means of mitigation is to establish a communication plan among relevant actors with monitoring mechanisms; and (v) the last risk is that if health information systems are not compatible between primary and secondary health facilities and the MOHW, the information will not flow as required, leading to patient care delays and lower quality services; this risk is classified as medium. The means of mitigation is to implement a robust contract system development to ensure compatibility.
III. IMPLEMENTATION AND MANAGEMENT PLAN
A. Summary of implementation arrangements
3.1 The borrower of the loan is Jamaica and the Executing Agency (EA) will be the MOFPS, which will be responsible for: (i) coordinating with the MOHW and other relevant entities involved in the PBP’s execution and presenting to the Bank evidence of the fulfilment of the policy conditions of the policy matrix; (ii) promoting actions to achieve the policy objectives defined in the Programme; and (iii) compiling, maintaining, and delivering to the Bank the necessary information, indicators, and parameters to monitor and evaluate Programme outcomes.
3.2 The disbursement of the second PBP operation is planned for the second semester calendar year of 2020.
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3.3 Special Contractual Conditions prior to single loan disbursement of the PBP: The single disbursement of loan resources will be subject to the Borrower’s compliance with the policy conditions of the second operation summarized in the Policy Matrix and the Policy Letter, as well as the compliance with the conditions contained in the loan contract.
B. Summary of arrangements for monitoring results
3.4 Monitoring. Programme monitoring consists of verifying the fulfillment of the policy measures agreed upon as disbursement conditions within the policy matrix and the means of verification. Said matrix specifies all the actions to be implemented in the program, the entities responsible for carrying out each activity, and the information that will allow the Bank to verify compliance. The outcomes of the implementation of the policies will be monitored through the indicators described in the results matrix. The Bank will coordinate with MOFPS, which is the executing agency, along with the MOHW and the PIOJ, the results monitoring. The MOFPS, MOHW and PIOJ will: (i) maintain official communication with the Bank and providing reports and evidence of the compliance; (ii) promote actions to achieve the policy objectives; and (iii) collect, file and deliver to the Bank all the information, indicators and parameters to monitor, measure and evaluate the results of the Programme.
3.5 Evaluation. The evaluation of the programmatic component will be part of the hybrid programme evaluation. The results matrix of the Programme includes indicators associated with the risk factors being addressed by the policy measures and will be tracked to determine their trends and impact on health outcomes and mortality. The MOFPS is the executing agency that will coordinate with the MOHW and the PIOJ the evaluation activities. The coordination comprises access to the sources of information, such as administrative records within the MOHW (i.e., hospital monthly statistical report, patient administration system, monthly clinic summary report.), and gathering of data from primary sources subject to approval by the MOHW. Also, it includes testing and implementing the evaluation tools during the project.
IV. POLICY LETTER
4.1 The Bank and the Government of Jamaica have agreed on the macroeconomic and sector policies set out in the Policy Letter (REL#1), which sets forth the strategy supported by the Programme’s areas of action described in this document.
Annex I - JA-L1086 Page 1 of 1
Development Effectiveness Matrix
Summary JA-L1086 I. Corporate and Country Priorities 1. IDB Development Objectives
-Social Inclusion and Equality -Gender Equality and Diversity Development Challenges & Cross-cutting Themes -Institutional Capacity and the Rule of Law
-Maternal mortality ratio (number of maternal deaths per 100,000 live births) Country Development Results Indicators -Beneficiaries receiving health services (#)*
2. Country Development Objectives
Improve the public health system; increase use of primary Country Strategy Results Matrix GN-2868 care facilities, reduce the disability-adjusted life years due to NCDs and the prevalence of associated risk factors
The intervention is included in the 2020 Operational Country Program Results Matrix GN-2991-1 Program.
Relevance of this project to country development challenges (If not aligned to Paragraph 1.47 country strategy or country program)
II. Development Outcomes - Evaluability Evaluable 3. Evidence-based Assessment & Solution 8.6 3.1 Program Diagnosis 3.0 3.2 Proposed Interventions or Solutions 4.0 3.3 Results Matrix Quality 1.6 4. Ex ante Economic Analysis N/A 5. Monitoring and Evaluation 9.3 5.1 Monitoring Mechanisms 2.5 5.2 Evaluation Plan 6.8 III. Risks & Mitigation Monitoring Matrix Overall risks rate = magnitude of risks*likelihood Medium Identified risks have been rated for magnitude and likelihood Yes Mitigation measures have been identified for major risks Yes Mitigation measures have indicators for tracking their implementation Yes Environmental & social risk classification B.13 IV. IDB´s Role - Additionality The project relies on the use of country systems
Financial Management: Budget, Treasury. Fiduciary (VPC/FMP Criteria) Yes Procurement: Information System, Price Comparison.
Non-Fiduciary Yes Monitoring and Evaluation National System.
The IDB’s involvement promotes additional improvements of the intended beneficiaries and/or public sector entity in the following dimensions:
Additional (to project preparation) technical assistance was provided to the public Yes 0 sector entity prior to approval to increase the likelihood of success of the project
Note: (*) Indicates contribution to the corresponding CRF’s Country Development Results Indicator.
Evaluability Note:
This project is the second operation of a PBP series. The first PBP operation was approved in 2018 as a hybrid operation that included an investment component. The program’s overall objective, which covers the PBP series and the investment loan, is to contribute to the improvement of the health of Jamaica’s population by strengthening comprehensive policies for the prevention of Non-Communicable (Chronic) Diseases risk factors and improved access to an upgraded and integrated primary and secondary health network in prioritized areas with an emphasis on chronic disease management that provide more efficient and higher quality care. The project has three components: 1) Macroeconomic stability, 2) Reduction of risk factors that cause NCDs, and 3) NCD early detection and clinical management.
The diagnosis presents a detailed explanation of the problems to be addressed, describing the challenges associated with the prevalence and treatment of NCDs in Jamaica, its main risk factors, and current policies and programs implemented to tackle these problems. In addition to the overall objective, the loan proposal’s vertical logic would have benefited from the explicit statement of specific objectives (concrete results) for the PBP series (although two specific objectives were included in the RM, these were not mentioned in the objectives section).
The RM presents adequate metrics at the results and impacts level. Outcome indicators are appropriately defined to assess project’s concrete results derived from the implementation of regulatory measures to reduce NCD risk factors and improve NCD early detection and management. Impact indicators reflect the contribution of the intervention to the overall objective of improving health. The proposed policy measures adequately build upon the policy conditions achieved with the first operation.
The evaluation plan proposes a difference-in-difference analysis to measure the combined effect of the policy and investment components of the overall program on selected outcomes of interest. The evaluation will rely on administrative health records as well as primary data collected from a baseline and follow up survey in 30 priority health centers (10 treated and 20 controls). Annex II - JA-L1086 Page 1 of 5
POLICY MATRIX
Objective: The objective of this Programme is to contribute to the improvement of the health of Jamaica’s population by strengthening comprehensive policies for the reduction of Non-Communicable (Chronic) Diseases risk factors and improved access to an upgraded and integrated primary and secondary health network in prioritized areas with an emphasis on chronic disease management, that provide more efficient and higher quality care. Within the overall programme, the specific development objectives of the second operation of the PBP are: (i) to promote regulatory and policy measures for the reduction of risk factors that cause NCDs; and (ii) to promote regulatory and policy measures to improve NCD early detection and clinical management.
STATUS OF THE POLICY CONDITIONS FOR POLICY CONDITIONS FOR FULFILLMENT OF SPECIFIC OBJECTIVES I PROGRAMMATIC (JA-L1080) II PROGRAMMATIC (JA-L1086) THE II PROGRAMMATIC1
Component 1. Macroeconomic Stability
Maintain a stable (1.1) Maintenance of an appropriate (1.1) Maintenance of an appropriate Fulfilled macroeconomic macroeconomic policy framework consistent macroeconomic policy framework framework, in line with with the programme’s objectives and in congruent with the programmme’s what is established in accordance with the provisions of the Policy objectives and in accordance with the the Policy Matrix and Matrix and the Policy Letter. provisions of the Policy Matrix and the Policy Letter. Policy Letter.
Component 2. Reduction of risk factors that cause NCDs
Reduce prevalence of (2.1). Decision by Cabinet to draft a Bill on (2.1a) Submission of the Draft Bill on To be Fulfilled, tobacco use in the Tobacco Control Legislation that is in keeping Tobacco Control Legislation to the fourth trimester of population. with the obligations under the World Health Legislative Committee of Cabinet that 2020. Organization (WHO) Framework Convention keeps with the treaty obligations under on Tobacco Control (FCTC), related, among the World Health Organization others to: (i) the regulation of interactions of Framework Convention on Tobacco GOJ officials with the tobacco industry; Control (FCTC), related, among others (ii) regulation of price and related measures, to: (i) the regulation of interactions of
1 This information is merely indicative as of the date of this document. As set forth in document CS-3633-2 (Policy-based Loans: Guidelines for Preparation and Implementation), compliance with all the conditions specified for disbursement, including the maintenance of an appropriate macroeconomic policy framework, will be verified by the Bank at the time of the request for the corresponding disbursement made by the Borrower and duly reflected in the Disbursement Eligibility Memorandum. Annex II - JA-L1086 Page 2 of 5
STATUS OF THE POLICY CONDITIONS FOR POLICY CONDITIONS FOR FULFILLMENT OF SPECIFIC OBJECTIVES I PROGRAMMATIC (JA-L1080) II PROGRAMMATIC (JA-L1086) THE II PROGRAMMATIC1 (iii) the full and mandatory prohibition on GOJ officials with the tobacco industry; tobacco advertising, promotion and (ii) regulation of price and related sponsorship, including a ban on point-of-sale measures, (iii) the full and mandatory tobacco displays; and (iv) compliance with the prohibition on tobacco advertising, Protocol to Eliminate Illicit Trade on Tobacco promotion and sponsorship, including a Products. ban on point-of-sale tobacco displays; and (iv) compliance with the Protocol to Eliminate Illicit Trade on Tobacco Products.
2.1b) Approval by Cabinet for Jamaica’s Fulfilled, third accession to the WHO FCTC Protocol to trimester of 2020. Eliminate Illicit Trade in Tobacco Products.
Reduction in Harmful (2.2) Development and approval by MOHW of (2.2) Approval by MOHW and Fulfilled, third consumption of alcohol. a Concept Paper for the Reduction of Harmful submission to Cabinet of the Reduction trimester of 2020. Use of Alcohol Policy aligned to WHO of Harmful Use of Alcohol Policy aligned guidelines and best buys regarding to WHO guidelines and best buys advertisement and sponsorship, availability regarding advertisement and and pricing and related measures. sponsorship, availability and pricing and related measures.
Jamaica Moves: Health (2.3) Within the Jamaica Moves at School (2.3) Within the Jamaica Moves at Fulfilled, second promotion and Programme, development and approval by School Programme, implementation of trimester of 2020. prevention of Non- MOHW of a plan to promote healthy eating the plan to promote healthy eating Communicable habits (that include provisions to limit the habits, physical activity and age Diseases (NCDs). sugar content of beverages offered at school), appropriate health check-ups, achieving physical activity (that include measures to at least the following results: (i) to facilitate increased physical activities amongst institutionalize at least one measure in at students) and age appropriate health check- least 50% of targeted schools that ups (that include strengthening capacity at facilitate increased physical activity schools to identify and respond to at-risk amongst students by June 2019; and (ii) students for NCDs). to institutionalize at least two measures in at least 50% of targeted schools that facilitate healthier food options by June Annex II - JA-L1086 Page 3 of 5
STATUS OF THE POLICY CONDITIONS FOR POLICY CONDITIONS FOR FULFILLMENT OF SPECIFIC OBJECTIVES I PROGRAMMATIC (JA-L1080) II PROGRAMMATIC (JA-L1086) THE II PROGRAMMATIC1 2019.”
Healthy diet: reduce (2.4) MOHW approval and Cabinet (2.4) Implementation of an Infant and Fulfilled, second malnutrition in infancy submission of an Infant and Young Child Young Child Feeding Policy and trimester of 2020. and childhood. Feeding Policy and strategic Plan to address Strategic Plan to address deficiencies deficiencies and obstacles experienced in and obstacles experienced in infant and infant and young child nutrition and to provide young child nutrition and to provide the the context for the development of innovative context for the development of innovative approaches to influence the determinants of approaches to influence the nutritional behavior, including exclusive determinants of nutritional behavior, breastfeeding during the first six-months of an demonstrated by: (i) at least five infant’s life, adequate complementary feeding, hospitals meeting the BFHI standards; support to the mother and the Baby Friendly (ii) at least 14 community support groups Hospital Initiative (BFHI). established; and (iii) at least 70 persons certified as Community Infant and Young Child Feeding Support Group Facilitators..
Healthy eating: (2.5) Implementation of the National Fulfilled, second providing useful and Food-based dietary guidelines through a trimester of 2020. actionable information social marketing campaign to inform to consumers. consumers regarding healthy eating habits
Component 3. NCD early detection and clinical management
Strengthening the (3.1) MOHW approval for the development of (3.1) MOHW approval of the CCM Fulfilled, second delivery system design a Chronic Care Model(CCM) Concept Paper Concept Paper, Policy and trimester of 2020. for priority NCDs Care. and Policy for the risk factor reduction, early Implementation Plan for the risk factor detection, treatment, diagnosis and support reduction, early detection, treatment, for priority NCDs(cardiovascular disease, diagnosis and support for priority NCDs diabetes; cervical, breast, prostate and (cardiovascular disease, diabetes; colorectal cancer; depression; asthma). cervical, breast, prostate and colorectal cancer; depression; asthma) and of a phased implementation of the plan to be piloted in at least one health network. Annex II - JA-L1086 Page 4 of 5
STATUS OF THE POLICY CONDITIONS FOR POLICY CONDITIONS FOR FULFILLMENT OF SPECIFIC OBJECTIVES I PROGRAMMATIC (JA-L1080) II PROGRAMMATIC (JA-L1086) THE II PROGRAMMATIC1
(3.2) MOHW approval of a Concept Paper for (3.2) Approval by MOHW and initiation of Fulfilled, third the Development of Screening Guidelines of the implementation of the screening trimester of 2020. Priority NCDs (hypertension; diabetes; guidelines for at least two of the priority cervical, breast, prostate and colorectal NCDs (hypertension, diabetes; cervical, cancer; depression) at the primary health care breast, prostate and colorectal cancer; (PHC) level to promote early detection. depression) at the PHC level in at least one health network to promote early detection.
Improving decision (3.3) Development of guidelines for the (3.3) Approval by MOHW and on-line Fulfilled second support for the delivery nutritional management of obesity, diabetes, publication of guidelines for the trimester of 2020. of priority NCDs care hypertension and cancer in hospital and nutritional management of obesity, through Guidelines of health center settings, which include the diabetes, hypertension and cancer in Standards of Care for development and implementation of the hospital and health center settings which Priority NCDs. nutrition care plan based on nutritional include (i) the development and adequacy, caloric control, nutrient density, implementation of the nutrition care plan variety and balance, as well as the individual based on nutritional adequacy, caloric anthropometric, biochemical, clinical and control, nutrient density, variety and dietary data; the evaluation, documentation balance as well as the individual and monitoring of nutritional care; directives anthropometric, biochemical, clinical and for self-management and indications for dietary data; (ii) the evaluation, referrals to health care team. documentation and monitoring of nutritional care; and (iii) directives for self-management and indications for referrals to health care team.
Strengthening of mental (3.4) Development of the National Strategic (3.4) Approval by MOHW of the National Fulfilled second, health services in Plan on Mental Health (NSPMH) with the Strategic Plan on Mental Health with the trimester of 2020. community-based objective, among others, to provide objective, among others, to (i) provide settings and of mental comprehensive, integrated, and responsive comprehensive, integrated and health promotion and mental health services in community-based responsive mental health services in prevention strategies. settings and to implement strategies for community-based settings; and (ii) to promotion and prevention in mental health. implement strategies for promotion and prevention in mental health. Annex II - JA-L1086 Page 5 of 5
STATUS OF THE POLICY CONDITIONS FOR POLICY CONDITIONS FOR FULFILLMENT OF SPECIFIC OBJECTIVES I PROGRAMMATIC (JA-L1080) II PROGRAMMATIC (JA-L1086) THE II PROGRAMMATIC1
Strengthening the (3.5) Development of the National Plan of (3.5a) Approval by Cabinet of the NPAI Fulfilled second Health Information Action for Information Systems for Health which includes among others: trimester of 2020. Systems for NCD (IS4H) which includes among others, (i) elements that will support a set of surveillance and clinical elements that will support a set of standards, standards, interoperability across monitoring and interoperability across components of components of information systems and evaluation. information systems and facilitate tracking of facilitate tracking of patients throughout patients throughout the public health sector, the public health sector; (ii) a referral referral system, modules to supported self- system; (iii) modules to support NCD management and follow-up appointments, as self-management and follow-up well as Telemedicine and Telehealth appointments; and (iv) telemedicine and initiatives. telehealth initiatives.
(3.5b) Implementation of the policy Fulfilled, second guidelines on Personal Health trimester of 2020. Information Protection (PHIP) for approval by the MOHW to govern the collection, use and disclosure of personal information whether it exists on paper or other formats.
Annex III - JA-L1086 Page 1 of 7 RESULTS MATRIX
Project The objective of this Programme is to contribute to the improvement of the health of Jamaica’s population by strengthening Objective: comprehensive policies for the reduction of Non-Communicable (Chronic) Diseases risk factors and improved access to an upgraded and integrated primary and secondary health network in prioritized areas with an emphasis on chronic disease management, that provide more efficient and higher quality care. Within the overall programme, the specific development objectives of the second operation of the PBP are: (i) to promote regulatory and policy measures for the reduction of risk factors that cause NCDs; and (ii) to promote regulatory and policy measures to improve NCD early detection and clinical management.
EXPECTED IMPACT1
Baseline Goal Means of Indicators Unit of measure Baseline Goal Comments Year Year verification Premature mortality ICD-10: I60-I69; rate for cerebrovascular 189.9 186.7 population 30-59 years accident (male) Pro-gender; gender tracking Premature mortality ICD-10: I60-I69; rate for cerebrovascular 126.1 124.1 population 30-59 years Deaths/ Register General’s accident (female) Pro-gender; gender tracking 100,000 inhabitants 2014 2023 Department Premature mortality ICD-10: E10-E14; Statistics rate for diabetes 65.1 64.0 population 30-59 years mellitus (male) Pro-gender; gender tracking Premature mortality ICD-10: E10-E14; rate for diabetes 70.2 69.0 population 30-59 years mellitus (female) Pro-gender; gender tracking Prevalence of diabetes mellitus for age group 9.0 9.0 45-74 (male) Prevalence of diabetes mellitus for age group 14.6 14.6 Baseline and goal will be % of the population Jamaica Health 45-74 (female) updated when the 2016/17 in each age group 2008 2023 and Lifestyle Prevalence of JHLS-III is available. Follow up with the disease Survey (JHLS). hypertension for age 31.7 31.2 will be done with JHLS-IV. group 45-74 (male) Prevalence of hypertension for age 35.8 35.2 group 45-74 (female)
1 This Result Matrix includes the impact indicators that were agreed with the MOHW in a special workshop after the approval of the first PBP operation and the investment operation. Annex III - JA-L1086 Page 2 of 7
Baseline Goal Means of Indicators Unit of measure Baseline Goal Comments Year Year verification Prevalence of obesity among girls, 13-15 % 10.3 2017 9.5 2023 Global school- years based student Prevalence of obesity health survey among boys, 13-15 % 9.9 2017 9.0 2023 (GSHS) years
EXPECTED OUTCOMES2
Unit of Baseline Baseline Goal Goal Indicators Means of verification Comments measure Value Year Value Year
Specific Objective 1: To promote regulatory and policy measures for the reduction of risk factors that cause NCDs. % of female students aged 13-15 years who smoke % 11 2017 10 2023 cigarettes % of male students aged 13-15 years who smoke % 19.1 2017 18 2023 cigarettes Definition: % of students who spent three or more hours Global school-based student per day sitting and health survey (GSHS) % of students aged 13-17 watching television,
years who are sedentary – % 62.7 2017 58 2023 playing computer Females (national level) games, or talking with friends, when not in school or doing homework during a typical or usual day % of students aged 13-17 years who are sedentary – % 49.8 2017 45 2023 Males (national level)
2 This Result Matrix includes the outcome indicators most relevant for each component of the second PBP operation and are a subset of the outcome indicators of the hybrid programme. Annex III - JA-L1086 Page 3 of 7
Unit of Baseline Baseline Goal Goal Indicators Means of verification Comments measure Value Year Value Year % of population aged 15- 74 who does not meet the Jamaica Health and Lifestyle recommended daily intake % 99.0 2008 90 2023 Survey (JHLS) of vegetables (national level) Specific Objective 2: to promote regulatory and policy measures to improve NCD early detection and clinical management. % of patients with NCDs that are treated according to protocols for screening, prevention, diagnosis, and % 0 2018 50 2023 Annual project audit management of diabetes and hypertension (target health centers) The survey diagnoses persons with % of men age 15-74 hypertension and asks aware of hypertension that them if they are aware % 31.2 2008 38 2023 have the condition of their condition and if controlled (national level) they are undergoing treatment for such Jamaica Health and Lifestyle condition. Survey (JHLS) The survey diagnoses
persons with % of women age 15-74 hypertension and asks aware of hypertension that them if they are aware % 44.9 2008 50 2023 have the condition of their condition and if controlled (national level) they are undergoing treatment for such condition.
Annex III - JA-L1086 Page 4 of 7
OUTPUTS – SECOND OPERATION OF THE PROGRAMMATIC POLICY-BASED LOAN SERIES
Unit of Goal Output Indicator measure Means of Verification Comments 2020 ment
Component 2. Reduction of risk factors that cause NCDs (2.1a) Submission of the Draft Bill on Tobacco Draft Bill 1 Letter from the Permanent The Bill keeps with the treaty Control Legislation to the Legislative Committee of Secretary (PS) of the MOHW obligations under the World Cabinet confirming Cabinet´s decision Health Organization Framework to submit the draft bill on Convention on Tobacco Control Tobacco Control Legislation in (FCTC), related, among others keeping with the obligations to: (i) the regulation of under the FCTC to the interactions of GOJ officials with Legislation Committee of the tobacco industry; Cabinet. (ii) regulation of price and related measures; (iii) the full and mandatory prohibition on tobacco advertising, promotion and sponsorship, including a ban on point-of-sale tobacco displays; and (iv) compliance with the Protocol to Eliminate Illicit Trade on Tobacco Products. (2.1b) Cabinet approval for Jamaica’s accession to Resolution 1 Letter from the PS of the the WHO FCTC Protocol to Eliminate Illicit Trade in by MOHW confirming Cabinet’s Tobacco Products. Cabinet approval for accession to the WHO FCTC Protocol to Eliminate Illicit Trade in Tobacco Products 2.2. Approval by MOHW and submission to Cabinet Policy 1 Letter from the PS of the This policy is aligned to WHO of the Reduction of Harmful Use of Alcohol policy. proposal MOHW confirming the guidelines and best-buys Ministry’s approval of the policy regarding advertisement and for the Reduction of Harmful sponsorship, availability and Use of Alcohol aligned to WHO pricing and related measures. guidelines and confirming the submission to Cabinet. 2.3. Within the Jamaica Moves at School Plan 1 Letter from the PS of the Plan will be considered Programme, implementation of the plan to promote MOHW submitting a report “implemented” if at least the healthy eating habits, physical activity and age showing the progress in the following results have been appropriate health check-ups. agreed areas. achieved: (i) to institutionalize at least one measure in at least 50% Annex III - JA-L1086 Page 5 of 7
Unit of Goal Output Indicator measure Means of Verification Comments 2020 ment of targeted schools that facilitate increased physical activity amongst students by June 2019; and (ii) to institutionalize at least two measures in at least 50% of targeted schools that facilitate healthier food options by June 2019.” 2.4. Implementation of an Infant and Young Child Policy 1 Letter from the PS of the This product will provide the Feeding Policy and Strategic Plan to address MOHW detailing the hospitals context for the development of deficiencies and obstacles experienced in infant and that (i) at least five hospitals innovative approaches to young child nutrition implemented. meet the BFHI standards; (ii) at influence the determinants of least 14 community support nutritional behaviour. groups were established; and Implementation will be (iii) at least 70 persons were demonstrated by (i) at least five certified as Community Infant hospitals meeting the BFHI and Young Child Feeding standards; (ii) at least Support Group Facilitators. 14 community support groups established; and (iii) at least 70 persons certified as Community Infant and Young Child Feeding Support Group Facilitators. 2.5. National Food-based dietary guidelines Guidelines 1 Letter form PS of MOHW with implemented through a social marketing campaign report including technical to inform consumers regarding healthy eating habits description of the social marketing campaign, the material, budget, and progress in the implementation. Component 3. NCD early detection and clinical management 3.1. MOHW approval of the CCM Concept Paper, Policy and Letter from the PS of the Priority NCDs include Policy and Implementation Plan for the risk factor implement MOHW confirming approval of cardiovascular disease, diabetes; reduction, early detection, treatment, diagnosis and ation plan the CCM Concept Paper, cervical, breast, prostate and support for priority NCDs and of a phased model policy and colorectal cancer; depression; implementation of the plan to be piloted in at least Implementation plan. asthma. one health network. 3.2. Approval by MOHW and initiation of the Guidelines 1 Letter from the PS of the Priority NCDs include Implementation of the screening guidelines for at MOHW confirming the approval hypertension, diabetes; cervical, Annex III - JA-L1086 Page 6 of 7
Unit of Goal Output Indicator measure Means of Verification Comments 2020 ment least two of the priority NCDs at the PHC level in at and initiation of implementation breast, prostate and colorectal least one health network to promote early detection of the national screening cancer; depression. approved by MOHW and initiated. guidelines for at least two of the priority NCDs (hypertension; diabetes; cervical, breast, prostate and colorectal cancer; depression) in at least one health network. 3.3 Approval by MOHW and on-line publication of Guidelines 1 Letter from the PS of the Guidelines include the guidelines for the nutritional management of obesity, MOHW confirming the approval development and implementation diabetes, hypertension and cancer in hospital and and link to the on-line of the nutrition care plan based health center settings publication of the guidelines for on nutritional adequacy, caloric the nutritional management of control, nutrient density, variety obesity, diabetes, hypertension and balance, as well as the and cancer in hospital and individual anthropometric, health center. biochemical, clinical and dietary data; the evaluation, documentation and monitoring of nutritional care; directives for self-management and indications for referrals to health care team. 3.4. Approval by MOHW of the National Strategic Plan 1 Letter from the MOHW The Plan’s objective is, among Plan on Mental Health confirming the approval of the others, to provide National Strategic Plan on comprehensive, integrated and Mental Health. responsive mental health services in community-based settings and to implement strategies for promotion and prevention in mental health. 3.5a. National Plan of Action for Information Plan 1 Letter from the Permanent The Plan includes among others, Systems for Health approved by Cabinet Secretary (PS) of the MOHW (i) elements that will support a set confirming Cabinet´s approval of standards, interoperability of the National Plan of Action across components of for Information Systems for information systems and facilitate Health. tracking of patients throughout the public health sector; (ii) a referral system; (iii) modules to support NCD self-management and follow-up appointments; and Annex III - JA-L1086 Page 7 of 7
Unit of Goal Output Indicator measure Means of Verification Comments 2020 ment (iv) as TeleMedicine and TeleHealth initiatives. 3.5b. Policy guidelines on Personal Health Guidelines 1 Letter from the PS of the The guidelines govern the Information Protection (PHIP) submitted for MOHW confirming the collection, use and disclosure of approval by the MOHW implementation of the policy personal information whether it guidelines on Personal Health exists on paper or other formats. Information Protection (PHIP).
DOCUMENT OF THE INTER-AMERICAN DEVELOPMENT BANK
PROPOSED RESOLUTION DE-__/20
Jamaica. Loan ____/OC-JA to Jamaica. Support for the Health Systems Strengthening for the Prevention and Care Management of Non-Communicable Diseases Programme II
The Board of Executive Directors
RESOLVES:
That the President of the Bank, or such representative as he shall designate, is authorized, in the name and on behalf of the Bank, to enter into such contract or contracts as may be necessary with Jamaica, as borrower, for the purpose of granting it a financing to cooperate in the execution of the Support for the Health Systems Strengthening for the Prevention and Care Management of Non-Communicable Diseases Programme II. Such financing will be for the amount of up to US$100,000,000 from the resources of the Bank’s Ordinary Capital and will be subject to the Financial Terms and Conditions and the Special Contractual Conditions of the Project Summary of the Loan Proposal.
(Adopted on ______2020)
LEG/SGO/CCB/EZSHARE-1331705865-8648 JA-L1086